Palliative care referral and associated outcomes among patients with cancer in the last 2 weeks of life

Palliative care from the perspective of cancer physicians: a qualitative semistructured interviews study

OBJECTIVE

Integrated palliative care for populations with cancer is now highly recommended. However, numerous physicians working in cancer care are still reluctant to refer patients to specialist palliative care teams. This study explores their perceptions of palliative care and factors influencing reasons to refer to specialist palliative care.

METHODS

We used a qualitative methodology based on semistructured interviews with physicians working in cancer care, in two tertiary hospitals and one comprehensive cancer centre with access to a specialist palliative care team. Forty-six physicians were invited and 18 interviews were performed until data saturation. Participants were mainly men, licensed in cancer care, 37.9 years old on average and had 13 years of professional experience. The length of interviews was on average 34 min (SD=3). Analysis was performed accordingly with the thematic analysis.

RESULTS

The data analysis found four themes: symptom management as a trigger, psychosocial support, mediation provided by interventions, and the association with terminal care or death. Palliative care integrated interventions were mainly perceived as holistic approaches that offered symptom management expertise and time. They were valued for helping in consolidating decision-making from a different or external perspective, or an 'outside look'. Several barriers were identified, often due to the confusion between terminal care and palliative care. This was further highlighted by the avoidance of the words 'palliative care', which were associated with death.

CONCLUSIONS

National policies for promoting palliative care seemed to have failed in switching oncologists' perception of palliative care, which they still consider as terminal care.

"When I Heard the Word Palliative": Obscuring and Clarifying Factors Affecting the Stigma Around Palliative Care Referral in Oncology

PURPOSE

Palliative care (PC) can help patients with cancer manage symptoms and achieve a greater quality of life. However, there are many barriers to patients with cancer receiving referrals to PC, including the stigmatizing association of PC with end of life. This study explores factors that obscure or clarify the stigma around PC referrals and its associations with end of life in cancer care.

METHODS

A qualitative descriptive design using grounded theory components was designed to investigate barriers to PC referrals for patients receiving treatment at an outpatient cancer center. Interviews with patients, caregivers, and oncology professionals were audio-recorded, transcribed, and independently coded by three investigators to ensure rigor. Participants were asked about their perceptions of PC and PC referral experiences.

RESULTS

Interviews with 44 participants revealed both obscuring and clarifying factors surrounding the association of PC as end of life. Prognostic uncertainty, confusion about PC's role, and social network influence all perpetuated an inaccurate and stigmatizing association of PC with end of life. Contrarily, familiarity with PC, prognostic confidence, and clear referral communication helped delineate PC as distinct from end of life.

CONCLUSION

To reduce the stigmatizing association of PC with end of life, referring clinicians should clearly communicate prognosis, PC's role, and the reason for referral within the context of each patient and his or her unique cancer trajectory. The oncology team plays a vital role in framing the messaging surrounding referrals to PC.

Access to Palliative Care for Critically Ill Cancer Patients in Mexico

OBJECTIVE

To determine the outcomes of hospitalized cancer patients requiring intensive care unit (ICU) intervention and receiving palliative care.

MATERIALS AND METHODS

An observational retrospective study was completed at a single academic critical care unit in Mexico City. All hospitalized cancer patients who were evaluated by the intensive care team to assess need for ICU were included between January and December 2018.

RESULTS

During the study period, the ICU group made 408 assessments of critically ill cancer patients in noncritical hospitalized areas. In total, 24.2% (99/408) of the patients in this population were consulted by the palliative care team. Of the patients evaluated, 46.5% (190/408) had advanced stage, but only 28.4% were receiving care by the palliative care team. The only risk factor for hospital mortality in the multivariate analysis was the quick Sequential Organ Failure Assessment (qSOFA) score at the time of the consultation by the ICU group (HR = 2.10, 95% CI = 1.34-3.29, p = 0.001). The median time between palliative care consultation and death was 3 days (IQR = 2-22). A total of 63% (37/58) of patients who were discharged from the hospital died during follow-up. The median follow-up time was 55 days (95% CI = 26.9-83.0). The overall mortality rate for the entire group during hospitalization and after hospital discharge was 80.8% (80/99).

CONCLUSION

Fewer than 3 out of 10 hospitalized cancer patients requiring admission to the ICU were evaluated by the palliative care team despite having incurable cancer. The qSOFA score of patients at the time of the ICU consultation was the only risk factor for mortality during hospitalization. Future research efforts in Mexico should focus on earlier integration of palliation care with usual oncology care in incurable cancer patients.

How Effective Is Palliative Care in Improving Patient Outcomes?

OPINION STATEMENT

As palliative care (PC) continues its rapid growth, an emerging body of evidence is demonstrating that its approach of interdisciplinary supportive care benefits many patient populations, including in the oncology setting. As studies and data proliferate, however, questions persist about who, what, why, when, and how PC as well as the ideal time for a PC consult and length of involvement. When comparing outcomes from chemotherapy trials, it is important to consider the dosing regimens used in the various studies. In the same way, it is important to account for the "dose" of the PC interventions utilized across studies, and apples to apples comparisons are needed in order to draw accurate conclusions about PC's benefits. Studies which include a true interdisciplinary PC intervention consistently show improvements in patient quality of life, as well as cost savings, with further study needed for other outcomes. These benefits cannot be extrapolated to care which may be labeled "palliative care," but which does not meet the standard of true interdisciplinary PC. The ultimate question is: Does PC indeed improve outcomes?

Quality of palliative care in identified palliative care beds

BACKGROUND

Dedicated identified palliative care beds (IPCB) are unique to France.

AIMS

This study aimed to assess their use and advantages in a medical oncology department of a private provincial hospital.

FINDINGS

Of the last 100 patients who died in the medical oncology department, 57 had an IPCB. Those with an IPCB had a longer final hospital stay and significant advantages for them were access to pain evaluation by nurses and professional psychological support. Opioid use was higher, but not significantly so. There were no significant differences for the presence of close relatives, physiotherapy interventions, social workers or specific anti-cancer treatment in the last 15 days of life.

CONCLUSION

This study shows some advantages for IPCB (treatment of pain, psychologist), which should be further explored. The length of the final hospital stay is controversial.

Cancer and end of life: the management provided during the year and the month preceding death in 2015 and causes of death in France

PURPOSE

The management of cancer patients at the end of life in France and their causes of death are not well known.

METHODS

People managed for cancer in 2014-2015, who died in 2015 and who were covered by the national health insurance general scheme (77% of the French population) were selected from the national health data system in order to analyze the health care reimbursed during the year and the month before their death.

RESULTS

This study included 125,497 people (mean age 73 years, SD 12.5) managed for cancer: colorectal: 12%, lung: 18%, prostate: 9%, breast: 8% and other: 62%. Almost 67% of people died in short-stay hospitals (SSH), 8% died in rehabilitation units (Rehab), 4% died in hospital at home (HaH), 5% died in skilled nursing homes (SNH) and 15% died at home or another place. The mean annual duration of all types of hospitalization was 70 days (SD 66) and 59% of patients had received hospital palliative care (HPC). During the last month of life, 42% of people had attended an emergency department at least once and people who had received HPC were less often admitted to an intensive care unit (10% versus 23%, 15% overall). During the month before death, 17% of patients had received intravenous chemotherapy (lung 23%, breast 21%) and 9% had received a pharmacy reimbursement for another form of chemotherapy (prostate 24%, breast 19%). The main cause of death was a tumour for 81% of patients: after management of lung cancer in 91% of cases, breast cancer in 81% of cases, colorectal cancer in 76% of cases and prostate cancer in 63% of cases.

CONCLUSIONS

Cancer management and death mostly occurred in SSH in France. Cancer patients frequently attend the emergency department and frequently receive chemotherapy during the last month of life. These data continue to contrast with those observed in Scandinavian- and English-speaking countries, in which management of the end of life at home is preferred.

Variations Among Physicians in Hospice Referrals of Patients With Advanced Cancer

PURPOSE

The benefits of hospice for patients with end-stage disease are well established. Although hospice use is increasing, a growing number of patients are enrolled for ≤ 7 days, a marker of poor quality of care and patient and family dissatisfaction. In this study, we examined variations in referrals among individuals and groups of physicians to assess a potential source of suboptimal hospice use.

METHODS

We conducted a retrospective chart review of 452 patients with advanced cancer referred to hospice from a comprehensive cancer center. We analyzed patient length of service (LOS) under hospice care, looking specifically at median LOS and percent of short enrollments (%LOS ≤ 7), to examine the variation between individual oncologists and divisions of oncologists.

RESULTS

Of 394 successfully referred patients, median LOS was 14.5 days and %LOS ≤ 7 was 32.5%, consistent with national data. There was significant interdivisional variation in LOS, both by overall distribution and %LOS ≤ 7 ( P < .01). In addition, there was dramatic variation in median LOS by individual physician (range, 4 to 88 days for physicians with five or more patients), indicating differences in hospice referral practices between providers (coefficient of variation > 125%). As one example, median LOS of physicians in the Division of Thoracic Malignancies varied from 4 to 33 days, despite similarities in patient population.

CONCLUSION

Nearly one in three patients with cancer who used hospice had LOS ≤ 7 days, a marker of poor quality. There was significant LOS variability among different divisions and different individual physicians, suggesting a need for increased education and training to meet recommended guidelines.